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Based on observation, interview and record review, the Condition of Participation: Staff and Staffing Responsiblities was not met as evidenced by the failure of the CAH to assure sufficient and knowledgeable staff was made available at all times to continuously monitor telemetry, assuring alarms were recognized, interpreted and acted on in a timely manner.

Refer to C-0253

Based on observation, interview and record review, the CAH failed to assure sufficient and knowledgeable staff was made available at all times to continuously monitor telemetry, assuring alarms were recognized, interpreted and acted on in a timely manner. Findings include:

Per observation on 4/12/16 and 4/13/16, telemetry (electronic monitoring of a patient's heart rate, rhythm and breathing at a remote location ) utilized on the Medical/Surgical Unit of the CAH was not consistently monitored by staff. During the 2 days of survey, observations were made of the telemetry system which includes a monitor located within the nurses's station and a second monitoring station in a room previously designated as part of of the Special Care Unit (SCU). As per physician assessment of diagnosis and clinical presentation, an order is written by the physician requesting telemetry monitoring for their patient. Nursing staff then apply a lead-transmitter system to each patient, which allows the patient to be mobile on the Medical/Surgical Unit without being attached to a lead-to-cable stationary monitor in their hospital room. With the present telemetry monitoring system, visualization of alarms, cardiac rhythms and oxygen levels can only be made by direct observation by staff of the telemetry monitor at the nurse's station or the second monitor station isolated in a room.

During a tour with the nurse manager of the Medical/Surgical Unit on 4/12/16 at 10:55 AM a telemetry alarm was sounding from the telemetry monitor located at the nurse's station. The alarm was not acknowledged until the nurse manager and the nurse surveyor entered the nurses's station and observed the alarm read "asystole" (no cardiac activity). The patient was checked by the nurse manager and the alarm was silenced at 11:02 AM. The surveyor was informed the patient's lead had been disconnected resulting in the alarm. When asked who was responsible for the monitoring of the telemetry system, the nurse manager stated the nursing staff is responsible. It was further acknowledged by the nurse manager the present monitoring response system in place "..is a problem...." given the nurses's present direct care responsibilities and the likelihood nurses will not be available to provide continuous monitoring of telemetry or to review alarms immediately and validated by patient assessment.

The failure to acknowledge telemetry alarms and the lack of constant monitoring was further confirmed on 4/12/16 when 6 patients were observed to be on telemetry. From 1:30 PM till 4:30 PM. there was no direct nursing staff consistently monitoring telemetry. Response time to alarms was from 2 to 8 minutes before a nurse acknowledged the alarm, reviewed the reason the alarm was sounded and chose to assess or not asses the patient. It was also noted at 2:12 PM an alarm sounded and continued for 2 minutes until a staff member, identified as not having training in cardiac rhythm/telemetry monitoring shut off the alarm. On 4/13/16, 5 patients were being monitored by telemetry. No one was assigned to provide constant monitoring of the telemetry patients. At 8:27 AM a telemetry alarm sounded and continued without acknowledgement by nursing staff for 17 minutes. During this time nursing staff had been seen entering the nurses station and leaving without addressing the alarm.

During observations on the Medical/Surgical on 4/12/16 and 4/13/16 there was a failure by nursing staff to acknowledge telemetry alarms and there was also a lack of constant monitoring of telemetry due to lack of sufficient staff. From 1:30 PM till 4:30 PM. there was no direct nursing staff consistently monitoring telemetry. Response time to alarms was from 2 to 8 minutes before a nurse acknowledged the alarm, reviewed the reason the alarm was sounded and chose to assess or not asses the patient. It was also noted at 2:12 PM an alarm sounded and continued for 2 minutes until a staff member, identified as not having training in cardiac rhythm/telemetry monitoring shut off the alarm. On 4/13/16, 5 patients were being monitored by telemetry. No one was assigned to provide constant monitoring of the telemetry patients. At 8:27 AM a telemetry alarm sounded and continued without acknowledgement by nursing staff for 17 minutes. During this time nursing staff had been seen entering the nurses station and leaving without addressing the alarm.

Per interview on 4/13/16 at 9:16 AM the Interim Chief Nursing Officer (CNO) acknowledged since accepting the CNO position approximately 6 weeks ago, concerns have been brought to his/her attention and the newly appointed Administration regarding the reconfiguration of the Medical/Surgical Unit which no longer included a SCU and dedicated staff who previously provided continuous telemetry monitoring of patients. As a result, discussions were in process with the medical and nursing staff to establish a plan that would assure patients placed on telemetry would be monitored continuously by staff who demonstrated proficiencies to monitor patients safely and effectively. However, the present lack of continuous monitoring, the delay in alarm response placed patients requiring telemetry at risk for the potential for possible harm.

Based on observations, interviews and record review the CAH failed to assure that care and services were provided in accordance with currently established written policies and procedures regarding the provision for patients requiring telemetry monitoring. Findings include:

Per review of the CAH policy Telemetry Procedure last approved/revised on 7/2015 states "Primary RN Responsibilities: D. Lethal rhythm alarms, once identified, will be immediately communicated to any and all RN's on the unit. F. Leads fail is considered a critical rhythm, and needs to be corrected within 5 minutes of the initial alarms". Although this policy provides a process for assuring patients requiring telemetry are closely monitored, the provision of this policy and process is not consistently being adhered to by nursing.

During a tour with the nurse manager of the Medical/Surgical Unit on 4/12/16 at 10:55 AM a telemetry alarm was sounding from the telemetry monitor located at the nurse's station. The alarm was not acknowledged until the nurse manager and the nurse surveyor entered the nurses's station and observed the alarm read "asystole" (no cardiac activity). The patient was checked by the nurse manager and the alarm was silenced at 11:02 AM. The surveyor was informed the patient's lead had been disconnected resulting in the alarm. When asked who was responsible for the monitoring of the telemetry system, the nurse manager stated the nursing staff is responsible. It was further acknowledged by the nurse manager the present monitoring response system in place "..is a problem...."

The failure to adhere to the CAH policy was further made evident during observations on the Medical/Surgical unit on 4/12/16 when 6 patients were observed to be on telemetry. From 1:30 PM till 4:30 PM. there was no direct nursing staff consistently monitoring telemetry. Response time to alarms was from 2 to 8 minutes before a nurse acknowledged the alarm, reviewed the reason the alarm was sounded and chose to assess or not asses the patient. On 4/13/16 5 patients were being monitored by telemetry. At 8:27 AM a telemetry alarm sounded and continued without acknowledgement by nursing staff for 17 minutes. During this time period nursing staff had been seen entering the nurses station and leaving without addressing the alarm. If the alarm identified a critical and/or lethal rhythm, the expectation of the policy was to identify and respond, however nursing did not demonstrate adherence to this policy by failing to acknowledge and review the alarm to rule out a critical need requiring an immediate response.

Based on observation and interview, nursing services failed to assure sufficient qualified staff was continuously available to meet the needs of patients requiring telemetry monitoring and nursing staff demonstrated a failure to acknowledge telemetry alarms. Findings include:

Per interview on 4/13/16 at 9:16 AM the Interim Chief Nursing Officer (CNO) acknowledged since accepting the CNO position approximately 6 weeks ago, concerns have been brought to his/her attention and the newly appointed Administration regarding the reconfiguration of the Medical/Surgical Unit which no longer included a SCU and dedicated staff who previously provided continuous telemetry monitoring of patients. As a result, discussions were in process with the medical and nursing staff to establish a plan that would assure patients placed on telemetry would be monitored continuously by staff who demonstrated proficiency with telemetry monitoring. However, it was further confirmed that presently nursing staff was insufficient to assure the needs of telemetry patients were being met.

The failure to acknowledge telemetry alarms and the lack of constant monitoring was further confirmed on 4/12/16 when 6 patients were observed to be on telemetry. From 1:30 PM till 4:30 PM. there was no direct nursing staff or other designated qualified individuals to consistently monitor telemetry. Response time to alarms was from 2 to 8 minutes before a nurse acknowledged the alarm, reviewed the reason the alarm was sounded and chose to assess or not asses the patient. It was also noted at 2:12 PM an alarm sounded and continued for 2 minutes until a staff member, identified as not having training in cardiac rhythm/telemetry monitoring shut off the alarm. On 4/13/16 5 patients were being monitored by telemetry. No one was assigned to provide constant monitoring of the telemetry patients. At 8:27 AM a telemetry alarm sounded and continued without acknowledgement by nursing staff for 17 minutes. During this time nursing staff were observed entering the nurses station and leaving without addressing the alarm or assessing the patient. It was also noted that the volume of the alarms could not be heard at the end of the long hallway where the public entrance/exit is located. On the morning of 4/13/16 the Assistant Nurse Manager for Medical/Surgical Unit also confirmed if staff where behind closed doors of a patient's room (depending on distance from nurses's station) the alarm sounds could be difficult to hear. Subsequently, when checking alarm volume on the telemetry monitor it was noted the volume had been set at a lower then acceptable range.

Further interview with Interim CNO on 4/13/16, s/he acknowledge nursing staff may also be experiencing "alarm fatigue" (lack of response due to excessive numbers of alarms/nuisance alarms that caregivers may disable, silence and/or ignore). However, presently it is the expectation if a nurse hears or observes an alarm from the telemetry monitoring system, it is their responsibility to recognize, interpret and act on alarms in a timely manner. When alarms are ignored, as observed, there is a failure to meet each patient's needs and the provision of nursing care specific to those patients requiring cardiac and/or oxygen level monitoring.

Based on observation and interview, the Quality Assurance program failed to fully assess and evaluate concerns identified by staff related to telemetry monitoring and failed to implement, in a timely manner, in conjunction with nursing and medical staff an appropriate corrective action. Findings include:

Per interview on 4/13/16 at 3:25 PM the Quality Assurance/Risk Manager confirmed although it was brought to the attention of Quality Assurance department the possibility telemetry patients may not have received the necessary monitoring to justify medical charges for this additional provision of care, there was a failure to further investigate the actual telemetry monitoring being provided. The Quality Assurance/Risk Manager confirmed 80 records had been audited to assure appropriate documentation was provided to justify medical billing charges for telemetry. However, there was a failure to investigate whether staffing patterns were sufficient, who was trained to monitor telemetry and whether corrective actions were needed beyond required reimbursement documentation. When informed of observations made by surveyors on 4/12/16 and 4/13/16 which included lack of acknowledgement of alarms and the absence of continuous monitoring of the telemetry patients, the Quality Assurance/Risk Manager stated "I thought someone was watching.....I was not aware...".